6 eye-popping findings from an investigation of the Washington, D.C., VA medical center

VA Secretary David Shulkin takes responsibility after a report found he improperly accepted Wimbledon tickets and taxpayer-funded airfare for his wife during a trip last year. He says he's eager to move forward and focus on fixing the VA.
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The Washington, D.C., headquarters of the U.S. Department of Veterans Affairs.(Photo: Donovan Slack, USA TODAY)

The $875,000 bed rental

The hospital paid exorbitant amounts for supplies and equipment, including $300 per speculum it could have bought for $122 each, and $900 each for a special needle that was available for $250. In one case, the hospital rented in-home hospital beds for three patients for three years — at a total cost of $877,000. The medical center could have bought the three beds for $21,000.

Surgical missteps

A review of 124 veteran patient records found problems with supplies or instruments in 74 of the cases between 2014 and 2017. One surgery was canceled after the patient was already under anesthesia because a retractor was unavailable — it had not been sterilized since its last use a week earlier. A surgeon had to improvise when a tool used to prepare a skin graft was broken and the graft failed. A surgical staff member had to run to a private-sector hospital across the street to borrow mesh to repair a hernia midprocedure.

What patient safety reports?

The hospital had more than 375 patient safety incidents because of supply problems between 2014 and 2016, but nearly half of them weren’t entered into a national VA database that tracks such incidents. In the local system where staff did track them, they failed to record how severe they were.

Medical record dump

Investigators seized more than 1,300 boxes of unsecured records from two warehouses, the hospital basement and a large trash dumpster in April 2017. Of those, 81% contained confidential patient information, including medical scans and records dating to the 1970s.

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Just park it in the warehouse

Investigators found more than 500,000 items which had been sitting for years in an off-site warehouse, including $80,000 worth of refrigerators, $25,000 worth of blood pressure cuffs, and 185 beds the hospital had acquired but found unusable. Two forklifts purchased for $44,000 in 2013 for use in the warehouse were too big to actually operate there. So hospital staff just parked them.

Multiple level failures

From 2013 to 2017, local, regional and national VA officials received at least 10 formal reports identifying issues with supplies and equipment, including medical instruments, that remained unaddressed last year.